Posted
by
Soulskill
on Wednesday October 14, 2009 @11:41AM
from the paging-dr-simpson dept.

jeffb (2.718) writes "As the LA Times reports, 206 patients receiving CT scans at Cedar Sinai hospital received up to eight times the X-ray exposure doctors intended. (The FDA alert gives details about the doses involved.) A misunderstanding over an 'embedded default setting' appears to have led to the error, which occurred when the hospital 'began using a new protocol for a specialized type of scan used to diagnose strokes. Doctors believed it would provide them more useful data to analyze disruptions in the flow of blood to brain tissue.' Human-computer interaction classes from the late 1980s onward have pounded home the lesson of the Therac-25, the usability issues of which led to multiple deaths. Will we ever learn enough to make these errors truly uncommittable?"